The Pharma-Physician Relationship

I have always maintained that Medicine (in context of pharmaceuticals) represents the most literal form of contemporary Practical Magic.

Consider this: You get sick and develop symptoms – almost feeling like a curse has been laid on you. Then, you’re prescribed tiny, innocuous (mostly white) pills to swallow. Soon, the tiny pills do their work, and almost magically, the curse is neutralized and you heal, feeling right as rain!

The fact that we know enough about the phenomenon of going from Sickness to Health by popping tiny white pills is a consequence of Science. Yet on some level, it borders on the magical, especially for the lay patient whose view on the Science is fairly limited!

The act of having (and more importantly, regaining) Good Health is a deeply personal experience, involving something so precious that Health is Wealth remains axiomatic through the ages!

This axiom is also why the hand (or physician/clinician/doctor) which magically restores a patient to health (using Science that is mostly invisible to the lay patient) is presumed as benevolent and is looked upon with enough implicit Trust as to allow wilful access to personal Privacy – an access so expansive that it borders on confessional!

It is in context of this implicit Trust that the Pharmaceutical companies’ relationship with Physicians (The Pharma-Physician Relationship or PPR) is viewed with anxiety and suspicion....

• So, what exactly is PPR?

To put it bluntly, PPR (in its current form) arose because the pharmaceutical industry has, over time, come to realize that building and sustaining strong ties with physicians is crucial to generate prescriptions (that further culminate in Sales/Revenue).

As a result, all pharmaceutical companies make it a part of their Sales & Marketing (S&M) efforts to connect with and cultivate ties with doctors, covering both traditional (including clinics, practices, hospitals, teaching and research institutions, conferences & meets) and novel (including social media – pages and groups, email campaigns, subscription- and newsletter platforms) touchpoints.

With the rise of Digitalization, all touchpoints have been leveraged to the hilt for prolific bestowing of items that range from printed stationery to more lucrative inducements such as a new cell phone, lump sum honoraria, a paid vacation (or all of the foregoing)!

• Why is PPR even necessary? Part #1 - The Patients’/Global Good Angle:

The Pharma-Physician Relationship is especially necessary in current times when the evolution of R&D is generating more information than ever before.

Further, with a severely skewed Patient: Physician ratio, an unmitigated burden on Physicians (that is leading to burnout), and the growing number of truly novel therapies (quite a few of which are personalized therapies such as CAR-T ), it is in everyone’s interest to ensure that physicians everywhere are kept updated on the latest options that are added to their armamentarium.

However, the trick is to be able to do so with as little (additional) pressure on physicians as possible – and there is no better way to do so than to get Pharma Reps to deliver targeted information (and product samples) to time-starved, burdened physicians while answering crucial questions on the way out!

• Why is PPR even necessary? Part #2 – The Business Angle:

We could argue that if a drug is good enough, it is in Society’s interest for the physicians to prescribe it – a bit like Ralph Waldo Emerson’s quote about “building a better mousetrap….” etc.

However, it’s not so simple when we consider that the Pharma industry is engaged in a field that isn’t just complicated (bordering on arduous) but also prohibitively expensive & prone to mistakes, besides dealing with Human beings – by far the most complex creation known to, well, Man!

Also consider that the day-to-day competition in this industry is beyond cut-throat and engages people who are typically rich in intellectual prowess – prowess that is being elevated to almost superhuman levels through the incorporation of Data Analytics and its descendants (like AI), pressuring this pool of smart people to deliver more results than possible through traditional hard work!

In this industry, any potential opportunity is often undergoing overlapping scrutiny and research by equally gifted competing pharmaceutical companies, narrowing both the advantages and the window of opportunity that any company in the space can hope to avail.

As a result of the foregoing, the Holy Grail of Novel Drug Development – “a differentiated, clearly better” drug is that much harder to find (and retain)!

So, unsurprisingly, “Me Too” products emerge more often than truly innovative ones.

Then, at the company level, there are addressable targets around R&D expenses, S&M costs, Insurance & Reimbursement coverage besides ensuring profitability and appreciation of shareholders’ value.

For the most part – all of this hinges on Three Key Drivers (TKDs): Reach, Pricing & Prescriptions written – with the last of the three being the true tipping point!

• How has the Business Angle overtaken the Patient’s Angle in PPR?

While Innovation is rare and celebrated as the supreme goal, in reality, even truly innovative products tend to languish and suffer when a company falters on above-indicated TKDs – and most often, all things being equal, it boils down to prescriptions written.

And if there are more “Me too” products than “differentiated, clearly better” ones (which was the case until fairly recently), winning or losing in the market really boils down to a Pharma company’s interpersonal relationships with physicians.

Consequently, Pharma companies have been forced to shift away from Pureplay Physician Detailing to Physician Detailing with Inducements to drive prescriptions.

Thanks to the focus on "prescriptions written" (and a concomitant glut of "Me Too" drugs), there isn’t enough of a differential between competing products to allow precedence to the Patient’s Angle (vs. the Business angle).

• What Harm is done by the Pharma-Physician Relationship in its current form?

While there are acceptable degrees of this Pharma-Physician consorting, patients are likely to face explicit harm when it takes on the shades of a cash-rich (extravagant?) partner incessantly plying the whims of a spoilt counterpart with gifts and sops to drive prescriptions.

Often, PPR-driven harm to patients is evident in the form of deliberate prescriptions of higher priced brands, inadequate disclosures regarding Patient Safety and related precautions, off-label scripts, and deliberate exposure to preventable risks (read Side Effects).

• Why does the Pharma-Physician Relationship go unchecked?

Besides the obvious necessity that pharma companies repeatedly advocate, the sheer pressure and aggression of driving products from bench to bedside makes the pharmaceutical industry an inexorable force that deploys a vast army of skilled Pharma Reps to do its bidding.

And given the scale and complexity of Healthcare per se, it is exceptionally hard to keep tabs on this army (of Pharma reps) while simultaneously working to govern the ethical purveyance of Healthcare.

The challenge is only compounded by the fact that inducements (to physicians) are firmly tied in with the otherwise accepted and necessary procedure of detailing physicians – whose to say if the rep only covered the drug-specific details or if s/he also threw in a free cruise (or an iPhone) while detailing?

As with most instances of collusion, neither the detailing rep nor the detailed physician would willingly disclose such details.   

• So, how is the Pharma-Physician Relationship being remedied?

Upon seeing how a deepening of the Pharma-Physician Relationship can cloud (or suspend) clinical judgment resulting in unethical practices and harm to patients, governments across the globe have decreed – either affirmatively or notionally, that “all Pharma companies must voluntarily disclose offered inducements and recipients for all such instances as are deemed reasonably capable of unduly influencing physicians’ clinical judgment and duties” (verbatim quote from a physician that I interviewed at length in Oct.2019).

Notable developments from direct intervention by government and regulatory bodies have been sporadic at best. However, two of my more memorable instances of this are showcased here and here.

In all honesty, the outcomes that followed have been a mixed bag but with clear high points nonetheless – interestingly, a lack of better outcomes has historically been attributed to notional implementation (and collusion).

• What more can be done about the Pharma-Physician Relationship?

Besides rigorous implementation and ad-hoc operations by independent watchdog units run by Regulatory bodies/Govts, there aren’t too many options out there just yet.

However, one aspect that consistently remains under-leveraged is that of Patient Empowerment & Advocacy.

If more patients are informed about their health-related choices and educated about the questions to address with their physicians, a further retuning of the Pharma-Physician Relationship is likely to follow swiftly.

In fact, based on extensive primary research with physicians and regulatory professionals, I firmly believe that adequately empowering patients might be just the kind of push that is needed to move the Pharma-Physician Relationship away from its current form of a “nexus-like engagement” to a relationship that truly benefits the patients.